2020 Camper Application

Step 1 of 7 - Camper Background

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If you require assistance completing any part of the application due to language or accessibility needs, please email director@campcasey.org so appropriate accommodations can be arranged.

Please completely fill-out this application to assist us in caring for the camper as safely as possible and so we may ensure the camper has a wonderful week at camp.
Near the end of this application, you will have an opportunity to submit medically relevant pictures that you believe would help us care for the camper (eg. AFO and sleep positioning). It is recommended that you prepare these before beginning the application.
After submitting this application, you will be contacted by a camper application committee member who will notify you regarding the status of your application.
If anything regarding the care of the camper changes between now and the start of camp, please contact your camper application committee member so we can have the most up-to-date information.

Will the camper be between the ages of 6 and 17 years old on July 26, 2020?*

Due to popularity and accommodations, we have to limit the ages of campers to those between 6 and 17 years old.

Yes

No

Is the camper's disability primarily physical in nature?*

Yes

No

Is the camper able to communicate basic needs and interests to people they do not know, even if it is non-verbally? Please note: volunteers are not all trained with ASL – American Sign Language.*

Yes

No

Does the camper use safe behavior for themselves and others? (We cannot accommodate children who have biting, kicking, punching or physical abusive behaviors. Campers need to stay with the group without one to one assistance. We average a two camper to one counselor ratio.)*

Yes

No

Has the camper been to Camp Casey before?*

Yes

No

We regret to inform you Kiwanis Camp Casey is a one-week summer camp for children ages 6 to 17 years of age who have the following characteristics.
1) Their disability is primarily physical.
2) They can communicate and engage with people they are not familiar and communicate basic needs and interests. Children who are non-verbal but have a clear yes and no and engage with other children at a cooperative play level are appropriate Kiwanis Casey Campers.
3) The camper must use safe behavior both for themselves and others.
As an all-volunteer non-profit, we are limited in our ability to provide direct one to one supervision and specialized training for our counselors which we feel the camper would need for a safe overnight camp experience.
One reference which may prove helpful in your search for summer camps is the resource listed in the
Parentmap Magazine
We wish you the very best.
If you have further questions, please email the camp director at director@campcasey.org

Parent/Guardian (This will be the first Parent/Guardian contacted by the Kiwanis):*

FirstLastRelationship to Camper

Parent/Guardian's Email:*

Parent/Guardian Primary Phone:*

TypePhone

Parent/Guardian Secondary Phone:

TypePhone

Parent/Guardian:

FirstLastRelationship to Camper

Parent/Guardian Primary Phone:

TypePhone

Parent/Guardian Secondary Phone:

TypePhone

Parent/Guardian's Email:

Additional Email for Communications:

Camper's Email:

Do you, as a parent/guardian of the camper, give permission for a member of the Kiwanis Camp Casey Camper Application Committee to contact the applicant's teacher/alternative via email or phone?*

Yes

No

Completion of a teacher questionnaire is required for each new camper applicant. If you have any questions about this
process please email or call camp director at: (206) 713-7515 or email at: director@campcasey.org

Please provide the contact information of the teacher/alternative.*

First and Last NamePhoneEmail

Emergency Contacts

In case of emergency where the parents or guardians cannot be reached, please list a contact person.
The contact should be able to make decisions and pick-up or make arrangement to pick-up the camper if needed.

First Emergency Contact:*

First and Last NameRelationshipPhone

Second Emergency Contact:

First and Last NameRelationshipPhone

Third Emergency Contact:

First and Last NameRelationshipPhone

Medical Information

Please provide medical contact information for the physician most familiar with the camper's care.

Insurance Name, group number, member ID:*

Insurance Phone Number:*

Physician Information:*

Physician NamePhysician Phone

Primary Disability/Medical Diagnosis:*

Resulting Physical Disability:*

Resulting Mental Disability:*

Does the camper have a school IEP?*

Yes

No

Please indicate if there are IEP Goals in the following:

Physical

Self-Help

Academic

Social

Behavior

Please Provide Camper's Physical IEP Goals.*

Please Provide Camper's Self-Help IEP Goals.*

Please Provide Camper's Academic IEP Goals.*

Please Provide Camper's Social IEP Goals.*

Please Provide Camper's Behavior IEP Goals and Behavior Plans.*

In what type of classroom does the camper receive most of their education?*

General Ed

Resource Room

Self Contained (please describe)

Other (please describe)

Please describe self contained classroom education.*

Please describe other classroom education.*

Does the camper have any allergies?*

Yes

No

Types of allergies and reactions. (Food dislikes are listed elsewhere.)*

Allergies to Medicines

Allergies to Foods

Other

Please describe all allergies and reactions.*

Is the camper up to date on immunizations?*

We strongly encourage campers to be up to date on their immunizations to help prevent the spread of preventable diseases while at camp and in the community.

Yes

No

My child is not immunized

We strongly encourage campers to be up to date on their immunizations to help prevent the spread of preventable diseases while at camp and in the community.

Does the camper take any medications?*

Yes

No

First medication:*

Medication NameDose (Number only, units entered later)

First medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

First Medication Schedule:*

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the first medication.*

Second medication:

Medication NameDose (Number only, units entered later)

Second medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Second Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the second medication.*

Third medication:

Medication NameDose (Number only, units entered later)

Third medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Third Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the third medication.*

Fourth medication:

Medication NameDose (Number only, units entered later)

Fourth medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Fourth Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the fourth medication.*

Fifth medication:

Medication NameDose (Number only, units entered later)

Fifth medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Fifth Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the fifth medication.*

Sixth medication:

Medication NameDose (Number only, units entered later)

Sixth medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Sixth Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the sixth medication.*

Seventh medication:

Medication NameDose (Number only, units entered later)

Seventh medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Seventh Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the seventh medication.*

Eighth medication:

Medication NameDose (Number only, units entered later)

Eighth medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Eigth Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the eighth medication.*

Ninth medication:

Medication NameDose (Number only, units entered later)

Ninth medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Ninth Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the ninth medication.*

Tenth medication:

Medication NameDose (Number only, units entered later)

Tenth medication dosage units

mg

mL

mcg

grams

Pills

Units

Tabs

Tenth Medication Schedule:

Breakfast

Lunch

Dinner

Bedtime

Other

If Other, please specify time below

Please explain the schedule for the tenth medication.*

If you have any additional medication entries, please enter them below by listing the name, dosage and schedule of the medication.

Please list any special medication instructions below.

Occasionally, campers may need certain over the counter (OTC) medications for minor ailments (headache, allergy, cough & cold, constipation, etc) while at camp. If you permit, our nurses will administer the appropriate OTC medication per their clinical judgement. Please indicate your preferences to allow our nurses to administer OTC medications if they feel it necessary:*

Yes, I give permission for my child to receive appropriate OTC medications administered by the nurse.

No, do not give any OTC medication without prior consent.

Please specify if there are any special instructions for administering OTC medications

Does the camper take medications with special foods?*

Yes

No

Please provide special food requirements for medication and provide enough to last the week.*

ALL Medications must be given to the nurses at check in before leaving for camp. DO NOT PACK your child’s medications.*

I acknowledge I have read the above statement

SPECIAL NURSING CARE OR CONCERNS

Does the camper have a VP shunt?*

Yes

No

If yes, describe any special monitoring or care required.*

Does the camper have history of seizures or blackouts?*

Yes

No

When was the last occurrence of a seizure or blackout?*

Please enter a best guess if exact date is unknown

Date Format: MM slash DD slash YYYY

If the camper does have a seizure or blackout at camp, we will contact you immediately. In the event we cannot reach you, please tell us what would warrant a visit to the emergency department.*

Has the camper had any recent surgeries that will impact care at camp?*

Yes

No

If yes, describe nature of surgery, including date(s).*

Does the camper have open sores or wounds that will require care at camp?*

Does the camper have appliances, retainers, contact lenses, glasses, etc. requiring special care?*

Yes

No

Please describe.*

Does the camper sunburn easily?*

Yes

No

Have there been any significant changes in family structure or social/emotional issues we should be aware of?*

Yes

No

Please provide a brief detail.*

List other concerns, special care required, or helpful hints

Eating and Nutritional Issues

Please indicate how much help the camper needs with eating.*

None

Partial help needed

Total help needed (Please provide detail)

Please give detail on the camper's eating needs.*

Does the camper have any special diet, food preparation or feeding technique requirements?*

Yes

No

Does the camper have a vegetarian diet?*

Yes

No

Please explain in detail anything you would like us to know about this aspect of the camper's diet.

Does the camper have a gluten-free diet?*

Yes

No

Is the camper gluten intolerant or have a gluten allergy?

Gluten Intolerant

Gluten Allergic

Gluten allergy (e.g. Celiac) is characterized by an immune response to gluten consumption.

Please explain in detail anything you would like us to know about this aspect of the camper's diet.

Does the camper have a blended diet?*

Yes

No

Please explain in detail anything you would like us to know about this aspect of the camper's diet.

Please provide any dietary information not covered by the above choices.

Does the camper have any extreme food dislikes?*

Yes

No

Please provide more detail.*

Does the camper have a feeding tube?*

Yes

No

Please indicate the camper's tube type.*

Please indicate the camper's feeding tube formula.*

Describe feeding schedule including name, type, amount, and times of supplement. (Be sure and send more than enough cans of food & feeding tube supplies)*

Provide the name(s) of other camper(s) the camper would like to eat with.

Bladder & Bowel Care

Indicate how the camper urinates.*

Sit

Stand

Urinal/leg bag

Diapers

Catheter (complete section below)

What help does the camper need?*

Support to sit or stand

Emptying, changing,cleaning

Transferring

Wiping

Diapers Changed

Bedpan/Urinal

None

Please explain typical transfer technique in detail.*

Please list at-home diaper change schedule.*

Please explain bedpan/urinal usage in detail.*

Does the camper require urinary catheterization?*

Yes

No

Describe schedule and specifics of bladder/catheterization program or reminder schedule:*

Assistance required.*

Total

Partial

Reminder Only

None

Please elaborate on what assistance is required.*

Does the camper require assistance with a bowel program?*

Yes

No

Detailed description of BM schedule.*

Does the camper have problems with constipation?*

Yes

No

How is constipation treated at home?*

Does the camper have an ostomy?*

Yes

No

Provide type of ostomy and care.*

*** All campers will be reminded to go to the bathroom or assisted if necessary.
Please be sure to send more than enough diapers, undergarments, catheters and ostomy supplies for the week, as well as any other special equipment for your child. We do not have extra supplies.

Speech

Please indicate the camper's speech ability.*

No Problem Communication

Understandable

Non-verbal

Please describe in detail how your child communicates a yes and no. How does your child communicate their needs and interests?

Special ways used to communicate.*

Sign Language

Alphabet Board

Augmented Communication System

None

Please only send communication devices that the camper uses independently with success with a variety of people. Please label all equipment. Other information about the camper’s communication (unique phrases or gestures to communicate needs, etc.)

Mobility and Special Equiptment

How will the camper move around at camp?*

Walks

Manual wheelchair-pushes self

Manual wheelchair-needs help

Power wheelchair

Uses cane

Uses walker

Other

Please explain Other camper mobility needs.*

*** We encourage power wheelchair drivers to bring their chairs to maximize independence at camp ONLY if you feel that they are responsible and skilled enough to safely drive with supervision at camp, including driving on uneven terrain, steep inclines, near curbs or in tight spaces with other children. Power wheelchairs can be broken at camp with the rough terrain and unfamiliar ground. Please be aware of this when deciding on the type of chair to send with the camper. Please understand that the Kiwanis cannot be held responsible for broken wheelchairs.

Does the camper require help transferring from bed to wheelchair?*

Independent

Needs stand by supervision/slight physical assist

Needs full physical assist

Does the camper require help transferring from ground to wheelchair or to stand?*

Independent

Needs stand by supervision/slight physical assist

Needs full physical assist

Does the camper require help transferring from wheelchair to toilet?*

Independent

Needs stand by supervision/slight physical assist

Needs full physical assist

Does the camper use a shower chair or other adaptations?*

Yes

No

Please elaborate on the equipment the camper uses for showering.*

Will you be packing (and labeling!) any specialized shower equipment? (Note: We will provide shower chairs, benches and handheld showerheads at camp.)*

Yes

No

How much assistance does the camper need with sitting without support?*

Independent

Needs stand by supervision/slight physical assist

Needs full physical assist

How much assistance does the camper need with changing positions in bed?*

Independent

Needs stand by supervision/slight physical assist

Needs full physical assist

Give any other information about the camper's mobility and special equipment needs.

AFO/DAFOs

Does your child utilize Ankle Foot Orthosis (AFO/DAFOs)?

Yes

No

When does your child utilize their AFO/DAFOs?

When is it appropriate to deviate from this schedule? e.g. If experiencing discomfort, based on level of activity, etc.

Please note we will make every effort to follow the most recent AFO schedule your child is using

Are there any additional details about AFOs/DAFOs you would like us to know?

Please list all mobility equipment, splints or orthotic equipment the camper will bring to camp. Also, please describe schedule of when equipment should be worn at camp (should be based on most current schedule used during summer). *** Be sure to label everything! Equipment Type (arm splint, dafo, etc.) How/when to be worn.

Hygiene

There are only showers at camp. We do adapt with hand-held shower heads and have several shower benches.

Does your child need any special bath adaptations?

Yes

No

Please describe these bathing procedures

List any special hygiene aides your child will pack.

Any additional hygiene details?

Dressing

How much help does the camper need with dressing?*

None (independent)

Partial help

Total help

Which side should be dressed first?*

Either

Right

Left

May we wash the camper’s clothes at camp?*

Yes

No

Recommendations*

*** Even if you do not use laundry services, please label all clothing and equipment with a laundry marker or iron on label.
*** Do not bring electronics, such as iPods or handheld consoles. Cell phones will be checked in with the barrack's captain.

I have read these recommendations

Night Care

Can the camper brush his/her own teeth?*

Yes

No

Please explain the camper's oral care procedure.*

Is the camper afraid of the dark?*

Yes

No

How is this handled at home?*

Has the camper spent a night away from home?*

Yes

No

Does the camper sleep with a special toy?*

Yes (Please label and send)

No

Should the camper be awakened at night to urinate?*

Yes

No

What time at home does the camper go the restroom? Please provide helpful detail.*

Are there other details about your child’s bedtime routine that would help the counselors?*

Name(s) of friends the camper would like to sleep near.

Activities & Other Information

Interest Groups
We cannot guarantee, but will make every effort for every camper to be able to participate with their top two choices for interest groups. Please choose the top three choices for interest groups with "1st" as the camper’s first choice.
**Interest Groups**
Science and Nature - You do science experiments and take nature walks.
Drama and Music - Put on a skit or play a concert.
Cooking - Stir up a masterpiece in the mess hall.
Arts & Crafts - Get your creative side roaring.
Sports - Let's get active!
Technology & Keeping Up with the Casey Bunch - Campers will learn how to set up a blog and or add posts and pictures to the Kiwanis Camp Casey Facebook Page.

Interest Group First Choice

Please do not select the same choice multiple times.

Interest Group Second Choice

Please do not select the same choice multiple times.

Interest Group Third Choice

Please do not select the same choice multiple times.

What are the camper's main interests and leisure activities?

We will be preparing a Camp Casey Directory to include each camper's name, address, phone, and birthday and email address. This directory will only be used by fellow campers, counselors and Kiwanis staff. Please indicate your preference for inclusion in the directory.*

Yes, include the camper's information

No, do not include the camper's information

May we have permission to use photographs of the camper for publicity purposes by the North Central Kiwanis Club or the news media?*

Yes

No

We are hoping each barracks will go swimming one time in the heated outdoor swimming pool. If the Casey Conference Center repairs and opens the pool they will provide trained certificated life guards and we have a one to one counselor to non-swimmer camper.

Does the camper use any special swimming equipment/clothing? Be sure to pack swim diapers, if appropriate and label all equipment.*

Yes

No

Please elaborate on what special equipment/clothing is used for swimming*

May we have permission to allow the camper to swim in a heated pool with a trained lifeguard and one counselor with each non-swimmer in the pool?*

Yes

No

What level of assistance does your child require while swimming?

Please state reasons why the camper is not allowed to participate in swimming.*

Traveling to Camp

Kiwanis provide bus transportation from a North Seattle location to and from camp for the convenience of our campers. We will no longer require first-year families to drive their camper to camp. We do not allow parents to visit during the week of camp as it contributes to amplified homesickness for the other campers and causes additional risk management concerns for Kiwanis leadership as we require background checks for all adults spending time at camp. If parents would like to visit camp, we strongly encourage that they drive their child to camp or pick their child up at the end of camp. Campers who are graduating can arrange for family to visit for carnival or the graduation program. Because Kiwanis must finalize the bus transportation contract by June 1st please communicate your final plans by this date.

Please answer this question, even if you elect to drive your child to camp. We make every effort to provide safe transportation using chartered buses traveling from north Seattle to camp on Whidbey Island. At camp, we will have a “field trip” day to either M-Bar-C Ranch for our younger campers or the Blue Fox Drive-In for our older campers. We usually order buses, one with a lift so that older or heavier campers can be lifted onto the bus and then transferred to the bus seat with the wheelchairs placed in a truck that travels with the buses. We need to know the exact number of campers who need ADA approved stay in wheelchair tie down on the bus seating.
Please answer the following:

Does the camper need to stay in their wheelchair with ADA approved tie downs for best head or trunk control and safety support?*

Yes

No

Can the camper sit next to a counselor on a bus seat, even if full physical assist is required, to transfer to bus seat?*

Yes

No

Does the camper require a car seat? (If so, please be sure to label and pack it)*

Yes

No

We strongly encourage first year campers be driven to camp by their parent/guardian. Unless special arrangements are made with camp director after phone interview, we request all first year campers to be driven to and from camp.

Travel to camp*

Drop-off at Camp Casey is free. Our buses leave from and return to 844 NE 78th St in Seattle. If you are planning on bringing the camper directly to camp on Sunday, it is important for us to know so we can plan transportation.
Bus - The camper will travel to Camp Casey on the provided bus transportation.
Drive - I will arrange to bring the camper directly to Camp Casey between 11:00am and 12:00 noon on Sunday.

Bus

Drive

We strongly encourage first year campers be driven to and from camp by their parent/guardian. Unless special arrangements are made with camp director after phone interview, we request all first year campers to be driven to and from camp.

Name and relationship of person dropping camper off.*

*** We will be checking identification of those picking up and dropping off campers.

Returning from camp*

Pick-up at Camp Casey is free. Our buses leave from and return to 844 NE 78th St in Seattle. If someone other than parent or legal guardian will be picking the camper up from camp, they must be designated in emergency contact section of application.
Bus - The camper will return from Camp Casey on the provided bus transportation.
Drive - I will arrange to pick the camper up at Camp Casey between 7:30am and 9:00am on Sunday.

Bus

Drive

Unless special arrangements are made with camp director after phone interview, we request all first year campers to be driven to and from camp.

Name and relationship of person picking up camper.*

*** We will be checking identification of those picking up and dropping off campers.

Counselors and nurses want the opportunity to learn your child's name before camp. Please provide a current picture. In addition, add any pictures that would help us provide care for your child. Examples would be splint or bedtime positioning.

Drop files here or

Accepted file types: jpg, gif, png, jpeg, zip, pdf.

Please feel free to provide us with any information you feel will help us care for the camper at camp.

In addition, if your application is very complicated or if you have routines or equipment that requires detailed knowledge, please contact us to arrange for a counselor or nurse home visit. We love to hear from our camper's parents!

Please read and agree to the forms below.

Please read Camp Casey Camper Code of Conduct. (link below)*

I have reviewed the Camper Code Of Conduct with the camper. We know what is expected and agree to the guidelines specified.

Please read Camp Casey Camper Release form. (link below)*

I have reviewed the Camper Release Form with the camper. We know what is expected and agree to the guidelines specified.

Campers ages 6 to 13 will need to complete the M-Bar-C Release form and mail/email it to the address listed at the end of the form.

It is with sadness but conviction that we must announce official cancellation of Kiwanis Camp Casey 2020 due to the impacts of COVID-19 in order to maintain the safety of our campers and volunteers. Please check back mid-May for our ideas for “Casey Stays Connected 2020.”